INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 25, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, MinSec Treatment LLC was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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705.24 (2) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
Based on a physical plant inspection on June 25, 2025, the facility failed to provide an operable soap dispenser in each bathroom. The client restroom on the right did not have an operable soap dispenser.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 7/8/2025 Client Bathroom on the right soap dispenser was changed. There will be a weekly site inspection by facility manager or designee to assure soap dispenser is in working condition. |
709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
Based on a review of eight client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in one record reviewed.
Client # 3 was admitted on September 10, 2024 and was discharged on March 6, 2025. The record contained documentation of a disclosure to an outside agency on September 10, 2024; however, there was no documentation that the facility obtained a release of information prior to the disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Manager reviewed with staff during staff meeting the requirements for having a consent signed for all outside agencies to include but not limited to the Department of Human Services. This consent was added to the intake paperwork so it will be completed during the intake process. Program manager or designee will audit at least 5 charts per week to assure all documentation including but not limited to consent form to Department of Human Services
Consents will be signed by all active clients who have Department of Human Service involvement completed by 7/29/2025. |
709.28 (c) (2) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on a review of eight client records, the facility failed to ensure that consent to release information forms included the information to be disclosed in one record reviewed.
Client # 8 was admitted on August 28, 2024 and was discharged on May 12, 2025. The record contained a release of information form to a lab that was signed by the client on August 28, 2024; however, the information to be disclosed was not documented on the form.
This is a repeat citation from the May 28, 2024 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program manager held a meeting with all staff in regards to repeat citations. Process of completing intake was discussed at the meeting. Information to be disclosed is to be checked off on the form.
Program Manager or designee will review charts on a weekly basis. Specific attention will be given to completion of ROI's.
Program Manager will coach staff as needed who may be in violation of this POC. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of client records, the facility failed to document an individualized treatment and rehabilitation plan was developed with the client within 30 days of admission, per the facility policy, in three of seven applicable records reviewed.
Treatment plans were not individualized as the goals, strengths, and supports were identical to those in the plan for other clients.
Client # 2 was admitted on August 27, 2024 and was discharged on May 23, 2025. The individual treatment and rehabilitation plan was due to be completed by September 26, 2024; however, it was not completed until October 2, 2024.
Client # 6 was admitted on February 21, 2025 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on March 17, 2025; however, it was not individualized as the goals, strengths, and supports were identical to those in the plan for Client # 7.
Client # 7 was admitted on July 1, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on August 15, 2024; however, it was not individualized as the goals, strengths, and supports were identical to those in the plan for Client # 6.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program manager held a staff meeting with all staff on 6/27/2025. Staff were given a training on the time frames of completing treatment plans and treatment planning being individualized to include individualized goals, strengths, and supports.
Program Manager or designee will pull 5 random charts per week for review. Specific attention will be given to completion treatment plans.
Program Manager will coach staff as needed who may be in violation of this POC. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to ensure that counseling services were provided according to the individual treatment and rehabilitation plans in six of eight applicable records reviewed.
Client # 2 was admitted on August 27, 2024 and was discharged on May 23, 2025. Treatment plans completed on December 2, 2024 and January 31, 2025, indicated that the client was to receive one individual counseling session per week; however, the record did not contain documentation of individual sessions during the weeks of January 6, 2025, January 13, 2025, February 24, 2025, and March 3, 2025.
Client # 3 was admitted on September 10, 2024 and was discharged on March 6, 2025. Treatment plans completed on September 10, 2024 and October 9, 2024, indicated that the client was to receive one individual counseling session per week; however, the record did not contain documentation of individual sessions during the weeks of September 23, 2024, November 4, 2024, and November 11, 2024.
Client # 4 was admitted on June 3, 2024 and was discharged on January 29, 2025. The treatment plan completed on December 17, 2024, indicated that the client was to receive one individual counseling session per week; however, the record did not contain documentation of individual sessions during weeks of January 13, 2025 and January 20, 2025.
Client # 5 was admitted on January 15, 2025 and was active at the time of the inspection. Treatment plans completed on February 13, 2025 and April 8, 2025 indicated that the client was to receive one individual counseling session per week; however, the record did not contain documentation of individual sessions during the weeks of March 31, 2025 and April 7, 2025.
Client # 7 was admitted on July 1, 2024 and was active at the time of the inspection. The treatment plan completed on October 3, 2024, indicated that the client was to receive one individual counseling session per week; however, the record did not contain documentation of individual sessions during weeks of January 20, 2025, January 27, 2025, and March 3, 2025.
Client # 8 was admitted on August 28, 2024 and was discharged on May 12, 2025. The treatment plan completed on March 6, 2025, indicated that the client was to receive one individual counseling session per week; however, the record did not contain documentation of individual sessions during weeks of March 31, 2025, April 7, 2025, and April 14, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Manager conducted a staff meeting on 6/27/2025 to include but not limited to proper documentation of records. It was discussed when a participant does not show up for a session, it must be documented on the Record of Service as a no show.
Program Manager will review 5 random charts weekly to assure all services attended or not are included on the Record of Service.
Program Manager will meet with counselor for coaching if this POC is violated. |
709.93(a)(8) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(8) Case consultation notes.
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Observations
Based on a review of client records and the facility's policy and procedure manual, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include case consultation notes, in six of eight records reviewed. The facility policy manual indicates that case consultation notes will be completed at three-month intervals during the first year of treatment.
Client # 2 was admitted on August 27, 2024 and was discharged on May 23, 2025. The record did not contain case consultation notes.
Client # 3 was admitted on September 10, 2024 and was discharged on March 6, 2025. The record did not contain case consultation notes.
Client # 4 was admitted on June 3, 2024 and was discharged on January 29, 2025. The second case consultation note was due to be completed by December 3, 2024; however, the record did not contain a second case consultation note.
Client # 5 was admitted on January 15, 2025 and was active at the time of the inspection. The record did not contain case consultation notes.
Client # 7 was admitted on July 1, 2024 and was active at the time of the inspection. The first case consultation note was due to be completed by October 1, 2024; however, the note was not documented until October 10, 2024. Additionally, the record did not contain any subsequent case consultation notes.
Client # 8 was admitted on August 28, 2024 and was discharged on May 12, 2025. The record did not contain case consultation notes.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Manager held a staff meeting on 6/27/2025 to discuss proper documentation in participant's chart to include but not limited to time frames in completing case consultations. Case consults will be completed during staff meetings on a bi weekly basis. Each staff member is to bring all case consults due in the staff meeting.
Program Manager will review 5 random charts weekly to assure all case consults are in the participant's chart
Program Manager will meet with counselor for coaching if this POC is violated. |
709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include follow-up information within 30 days of discharge, per facility policy, in four of five applicable records reviewed.
Client # 1 was admitted on August 9, 2024 and was discharged on September 10, 2024. The client record did not contain documentation of follow-up information.
Client # 3 was admitted on September 10, 2024 and was discharged on March 6, 2025. The client record did not contain documentation of follow-up information.
Client # 4 was admitted on June 3, 2024 and was discharged on January 29, 2025. The client record did not contain documentation of follow-up information.
Client # 8 was admitted on August 28, 2024 and was discharged on May 12, 2025. The client record did not contain documentation of follow-up information.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Immediately upon discharge Program Manager will document on spreadsheet discharge date and type of discharge. This information will be added to Program Manager's calendar for a follow up call 30 days after discharge. The follow up calls will include successful, administrative and unsuccessful discharges. |